Dr. Koch is Adjunct Assistant Professor, Valparaiso University College of Nursing, Valparaiso, Indiana.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. The author thanks Carole A. Pepa, PhD, RN, for her support and guidance during initial manuscript development.
Address correspondence to Julie A. Koch, DNP, RN, FNP-BC, Adjunct Assistant Professor, Valparaiso University College of Nursing, 836 LaPorte Avenue, Valparaiso, IN 46383; e-mail: Julie.firstname.lastname@example.org.
Streptococcus pneumoniae-associated infections cause significant morbidity and mortality in older adults. Twenty percent of older adults with pneumococcal pneumonia die within the first week of hospitalization, despite improvements in supportive intensive care and availability of numerous antibacterial agents (Kruspe et al., 2003; Rubins & Janoff, 2001). Although significant mortality results from localized respiratory infection, invasive pneumococcal disease poses a more ominous threat to older adults, and the emergence of drug-resistant bacterial strains creates additional challenges. Nearly 40,000 cases of invasive pneumococcal infection (i.e., sepsis and meningitis) occur annually (Centers for Medicare & Medicaid Services [CMS], 2009). Fatality rates can soar up to 80% in cases of bacterial meningitis in older adults (Immunization Action Coalition, 2010; Kruspe et al., 2003). Not surprisingly, pneumococcal disease presents a substantial target for vaccine-preventable, bacterial death in those 65 and older. Yet, numerous provider- and patient-based barriers to immunization persist. Advanced practice nurses, with their focus on health promotion and disease prevention, are in prime positions to use evidence-based strategies to overcome these barriers.
Historically, barriers to the administration and receipt of pneumococcal vaccine have been well documented. To overcome financial barriers, the federal government initiated Medicare payment for the pneumococcal polysaccharide vaccine (PPSV) in 1981. The advent of Medicare coverage for PPSV resulted in modestly increased immunization rates in the 1980s.
Still, only 14.1% of adults 65 and older reported ever having received a PPSV by 1989 (Centers for Disease Control and Prevention [CDC], 2010). To strengthen provider awareness, the U.S. Department of Health and Human Services (USDHHS) established the Healthy People 2000 goal of 60% pneumococcal and influenza vaccination rates; by 1991, more than 20% of older adults had been vaccinated (CDC, 2010). Rates further increased in the 1990s, as the CDC and the Health Care Financing Administration developed an action plan targeting hospital-based vaccination policies (Flanders, 2001). By 2000, Americans had achieved the Healthy People goal for influenza, but only 52.9% of older adults reported having received a PPSV (CDC, 2010).
Health care providers were then challenged by the new Healthy People 2010 goal of 90% coverage for both influenza and pneumococcal vaccines. Yet, research indicated that even with Medicare coverage and a national action plan, PPSV was still underused. Two thirds of patients who developed a serious pneumococcal infection had been hospitalized at least once in the previous 3 to 5 years (Flanders, 2001). In response to vaccine underutilization, CMS enacted regulation allowing the use of standing orders within hospitals and long-term care facilities (Fields & Nicastri, 2004).
While current policies have improved the number of individuals immunized in hospital settings, overall vaccination rates have tapered off in recent years (CMS, 2009). Nationwide, 64.3% of White, 44.6% of Black, and 36.4% of Hispanic adults 65 and older report ever having received a pneumococcal vaccine (CDC, 2010). Without further intervention, aging American demographics are anticipated to magnify this problem. In 2030, the older adult population is projected to be twice as large as in 2000, representing nearly 20% of the total population (Federal Interagency Forum on Aging-Related Statistics, 2008). Furthermore, although Russo and Elixhauser (2006) noted that older adults account for one third of all hospitalizations, targeting this population misses the majority of older adults—those who are not hospitalized during any given year.
The strongest predictive factor for PPSV among individuals 65 and older has been relatively straightforward: whether their health care provider ever offered the vaccine (Ehresmann et al., 2001; Winston, Wortley, & Lees, 2006). Consistent with this evidence, Ehresmann et al. (2001) reported that older adults indicated they preferred to receive the PPSV at their provider’s office, with patients being 21.7 times more likely to be immunized if they were offered the vaccine by their clinician. In addition, most older adults reported visiting their health care provider at least once within the past year (CMS, 2009; Ehresmann et al., 2001); therefore, the health care office or clinic is an optimal site to reach older adults.
Unfortunately, a solution is not as straightforward. The nation’s inability to meet the Healthy People goals reflects the complexity of the issue. Further increases in immunization rates toward the 90% target of Healthy People 2010 are unlikely without identifying strategies that overcome the barriers to vaccine administration and acceptance. Without a corresponding increase in immunization rates, the nation will not meet the Healthy People 2020 goal of decreasing the number of cases of invasive pneumococcal infection (from 40.4 per 100,000 adults 65 and older in 2008) to no more than 31 new cases per 100,000 older adults (USDHHS, 2011).
Despite the efficacy of provider recommendations, clinicians face a number of competing demands within day-to-day practice (e.g., higher acuity of visits, focus on productivity). Overcoming barriers is a key strategy to increasing vaccine acceptance. Furthermore, it is important for advanced practice nurses to examine strategies that work to avoid focusing limited resources (personnel, finances, and time) on interventions that are not effective.
A near endless combination of practice, provider, and patient factors create unique office environments that result in a wide range of immunization rates across the nation. To assist health care providers caring for older adults, an integrative review was performed to examine interventions with demonstrated efficacy in improving pneumococcal vaccination rates in office settings. Thus, the purpose of this integrative review was to answer one primary question: What strategies have demonstrated efficacy in improving pneumococcal vaccination rates in older adults in an office setting?
This integrative literature review followed methodological strategies identified by Whittemore and Knafl (2005). Database sources examined included CINAHL, Proquest Nursing and Allied Health Source, MEDLINE via EBSCO, Sociological Abstracts, PsycARTICLES, and the Cochrane Library. The MeSH (medical subject heading terms) system was used to explore keywords for consistency and applicability. The keywords pneumococcal, vaccine or immunization, strategy or intervention, and adults or older adults were used to search databases for peer-reviewed literature with human participants published in English from January 1, 2000 to September 1, 2010. Within the Cochrane Library, the search was limited to literature with the defined search terms listed in the title or abstract or designated as keywords.
After elimination of duplicate citations among all searched databases, a total of 74 abstracts were initially reviewed. Exclusion criteria used for the abstract review included (a) studies conducted solely outside the United States, (b) interventions initiated for inpatients or outpatients in a hospital emergency department, (c) barriers identified without evaluation of a practice characteristic, strategy, or intervention; and (d) outcomes other than vaccination rates (e.g., cost effectiveness). Additionally, systematic reviews, meta-analyses, integrative reviews, editorials, commentaries, and unpublished manuscripts were excluded. Following a review of abstracts, 36 articles were obtained for appraisal; a hand search of the reference list of acquired articles was undertaken using the same inclusion and exclusion criteria. After a full text review, 12 documents were included in quality appraisal.
During the quality assessment for this integrative review, an instrument incorporating Whittemore’s (2005) study constructs believed to affect quality was used to systematically appraise primary research. The instrument focused on eight study constructs: (a) sample, (b) study protocol, (c) measurement, (d) attrition, (e) threats to validity, (f) statistical analysis, (g) discussion, and (h) intervention. Based on scoring within subsets of these categories, articles were then ranked as good, fair, or poor quality. One study, rated as poor quality, was eliminated from this integrative review. Eleven documents were included for data extraction and synthesis; a summary of this literature can be found in the Table.
Improvements in pneumococcal immunization rates have occurred most consistently when a health care system supports activity performance through organizational changes in clinical procedures and staffing (Chi, Reiber, & Neuzil, 2006; Nowalk, Bardella, Zimmerman, & Shen, 2004; Zimmerman et al., 2009). Nowalk et al. (2004) reported that an increased number of nurses and other support staff was associated with higher pneumococcal vaccination rates. Nowalk et al. also found that the number of office systems in place for promoting immunization, along with the time allotted for adult acute care visits, nearly doubled the likelihood of being up to date with the PPSV. In a later study, Zimmerman et al. (2009) found those offices that had implemented immunization promotion strategies (i.e., designated vaccination clinics, computerized immunization tracking systems, prompts on patient charts, and a source of free or reduced-cost vaccinations) had higher vaccination rates. Zimmerman et al. reported that increased time spent with patients for well visits was most closely associated with increased PPSV rates.
Provider reminders, when maintained by organizational change, can be very effective. However, when the reminders are removed, efficacy may not be sustainable (Fishbein, Willis, Cassidy, Marioneaux, & Winston, 2006). Data to support the use of provider reminders have been inconsistent within the literature. Santibanez, Zimmerman, Nowalk, Jewell, and Bardella (2004) reported higher percentages of older adults immunized with the PPSV in offices promoting vaccination through provider reminders (77% versus 63%). Fishbein et al. (2006) reported a lack of a consistent increase in immunization rates when provider reminders were instituted. However, the availability of information technology to generate reminders and access clinical guidelines was found to modestly increase the number of Medicare beneficiaries receiving the PPSV (Pham, Schrag, Hargraves, & Bach, 2005). Latessa, Cummings, Lilley, and Morrissey (2000) noted a more significant increase in PPSV rates when a provider reminder was added to patient education.
When provider feedback is used as an integral component of organizational change, audit and feedback can increase PPSV rates. Quinley and Shih (2004) found that mailed feedback combined with a provider reminder increased PPSV coverage rates by an average of 10%; high-volume practices saw a 12% increase, while practices serving the Black community had only a 5% increase.
Little has been published within the past decade regarding the effect of provider education on vaccination rates. Quinley and Shih (2004) included provider education in their study evaluating the effects of telephone reminders to providers, but the portion of the effect related to the educational component was not differentiated.
Patient reminders have demonstrated effectiveness in increasing pneumococcal vaccine rates (Johnson et al., 2003; Terrell-Perica, Effler, Houck, Lee, & Crosthwaite, 2001; Winston, Mims, & Leatherwood, 2007). Older adults who received telephone reminders in a study conducted by Winston et al. (2007) were more likely to be vaccinated than the control group (17% versus 8%). Other researchers noted only modest success with reminder letters. Johnson et al. (2003) found a 3.7% increase in PPSV rates when mailed reminders were added to a community-wide education campaign. Terrell-Perica et al. (2001) reported a more than 3% increase in PPSV rates when a combined influenza and pneumococcal immunization reminder letter was used; however, this increased effect persisted for only 5 to 7 weeks.
Surprisingly, patient-based education was one of the least effective single interventions. Fishbein et al. (2006) reported a lack of a consistent increase in immunization rates when patient education was combined with provider reminders. Latessa et al. (2000) reported a modest increase (4%) in pneumococcal immunization rates attributed to the use of a patient education sign placed in examination rooms. Johnson et al. (2003) found that a 10% increase in awareness of the PPSV resulted in only a 3.7% increase in immunization.
Health care systems and policy changes have been critical in increasing PPSV rates to current levels. The 40% increase in national immunization rates from 1990 to 2010 can be attributed to Medicare coverage of the cost of vaccination, national campaigns to raise public and provider awareness, and widespread availability of recommended vaccine guidelines. However, the nationwide statistic of 64.3% of White, 44.6% of Black, and 36.4% of Hispanic adults 65 and older ever having received a pneumococcal vaccine (CDC, 2010) remains far from the previously established Healthy People 2010 targeted 90% immunization goal.
An additional challenge faces health care providers. Although evidence supports the vaccine’s efficacy in reducing the incidence of invasive pneumococcal disease (i.e., sepsis and meningitis) that contributes to the death of nearly 2,000 older adults each year (CMS, 2009), health care providers need to make significant improvements to vaccination procedures to decrease the number of cases of invasive pneumococcal infection from 40.4 per 100,000 adults 65 and older in 2008 to the Healthy People 2020 goal of no more than 31 new cases per 100,000 older adults (USDHHS, 2011).
There is growing evidence that multicomponent, system-wide changes (e.g., standing orders, computer-generated provider reminders combined with patient reminders) are needed to integrate pneumococcal vaccination into routine clinical care so patients may receive the full benefit of evidence-based practice. The findings of this integrative review of the literature support the need for sustained organizational change to enhance PPSV rates.
One of the most effective demonstrations of organizational change has occurred within U.S. Department of Veterans Affairs (VA) health facilities. These facilities have (a) incorporated vaccination rates as performance indicators, (b) integrated electronic medical record (EMR) systems that maintain patient vaccination history and generate automated provider reminders, (c) used direct patient reminders, and (d) initiated standing orders (Chi et al., 2006). As a result of this multimodal approach, veterans receiving care in VA health facilities reported higher pneumococcal vaccine coverage than their non-VA peers; VA care has been associated with a nearly twofold increase in pneumococcal vaccination rates as compared with veterans cared for outside the VA system (Chi et al., 2006).
The multifaceted aspects of organizational strategies also surfaced throughout other studies evaluated in this integrative review (Nowalk et al., 2004; Zimmerman et al., 2009), and findings are consistent with an earlier meta-analysis published by Stone et al. (2002). Yet, health care providers may need significant support to sustain change. Whether this change can be maintained by the available resources in many offices and clinics was not confirmed in this review.
Previously published systematic reviews noted the effectiveness of provider and patient reminders (Balas et al., 2000; Briss et al., 2000; Jacobson Vann & Szilagyi, 2005; Szilagyi et al., 2000). Within the studies included in this integrative review, provider and patient reminders appear to hold some promise for continued efforts to increase PPSV rates. When supported by changes within the organization, reminders can be used successfully to increase PPSV rates (Latessa et al., 2000; Santibanez et al., 2004). When combined with other interventions, patient or provider reminders also increased immunization rates; yet, telephone reminders were shown to be one of the most effective single interventions (Winston et al., 2007). Telephone reminders would allow the sustained use of resources (personnel and technology) considered standard within all offices and clinics. The efficacy of telephone reminders supports the opinion that interventions do not necessarily need to be elaborate to be effective.
Of particular interest was Pham et al.’s (2005) evaluation of provider feedback in the form of EMR prompts. Hospitals have used EMR prompts, along with standing orders, to increase immunization rates. But, as outpatient offices and clinics within the United States transition to EMR, added stress to organizational systems may negatively impact PPSV immunization rates. With a continued focus on productivity, providers may be so overwhelmed transitioning to the new system that electronic prompts for immunizations are ignored or overridden.
Interestingly, the use of provider and/or patient education was not supported by the literature. Although other descriptive studies and integrative reviews reported provider and patient education to be essential to increasing PPSV rates (Mieczkowski & Wilson, 2002; Santibanez et al., 2002), these findings were not supported within this integrative review. However, Mieczkowski and Wilson’s (2002) earlier review noted the effectiveness of patient education in a predominantly Black population. Therefore, the area of patient education warrants further examination in efforts to decrease disparity of PPSV rates.
Although the integrative review followed a rigorous, organized approach and included a broad base of research available for review—from descriptive studies to randomized controlled trials—several limitations became apparent during data analysis. The limitations are not thought to impact the quality of the review, but do warrant addressing.
Organizational change or multi-component interventions were frequently evaluated within the literature reviewed. But when multicomponent interventions demonstrated effectiveness, some researchers did not examine the effectiveness of each individual component. Therefore, it could be difficult to determine which component contributed to the noted improvement. This factor posed challenges for data extrapolation and could affect applicability of findings.
Apparent disparities in provider recommendation and patient acceptance of PPSV between racial and ethnic minority groups is of particular concern. Minorities were underrepresented within the studies included in this integrative review. Therefore, limitations of the evidence available for review did not afford the opportunity to determine whether the strategies outlined in this review would be effective in increasing PPSV rates in racial and ethnic minority populations.
Specific decisions in the early development of the integrative review limited the studies reviewed. Previously published systematic reviews of the literature have focused on financial incentives for patients, including reducing out-of-pocket costs. This strategy was not included within this integrative review because government programs have eliminated the Medicare deductible and copayment for PPSV. Because of the established strong link between provider-offered PPSV and vaccination rates, this literature review focused on strategies that would enhance immunization administration within an office or clinic setting. Immunization administration within emergency departments, patient homes, pharmacies, and grocery stores was intentionally omitted. Increasing access to vaccination at these locations could be equally important to meeting the Healthy People 2010 and 2020 goals. Finally, limitation to studies taking part in the United States afforded an examination of what has worked for older Americans but did not allow insight into strategies that have been effective primarily in regions outside of the United States.
Implications for Nursing Practice
Clinical implications of the findings of this integrative review are multifaceted. Changing demographics as adults live longer with chronic diseases are resulting in higher acuity of office visits. Yet, time allotted for these visits, found to be linked to increased PPSV rates (Nowalk et al., 2004), can be limited as practices continue to focus on productivity. Not surprisingly, the literature supports nurses’ role in enhancing vaccination rates (Chi et al., 2006; Nowalk et al., 2004; Winston et al., 2007). As the nation transitions to EMR, this role may become more critical; electronic reminders may prompt nurses to immunize outpatients under standing orders. Additionally, advanced practice nurses can assume leadership roles in the planning and implementation of multicomponent organizational change that includes EMR.
More research is needed to determine cost- and time-effective strategies to decreasing racial disparities. Since minorities often decline immunizations when offered (Quinley & Shih, 2004; Winston et al., 2006; Zimmerman et al., 2009), increasing minority demand is a key factor for improving vaccine rates in this population. As the research reviewed and previously published systematic reviews and meta-analyses determined, patient education did not remarkably increase PPSV rates (Briss et al., 2000; Johnson et al., 2003; Latessa et al., 2000; Stone et al., 2002); therefore, other areas need to be explored. Advanced practice nurses can work with thought leaders within minority communities to explore avenues to reach unimmunized older adults.
Advanced practice nurses may also add to the body of knowledge regarding immunizations and older adults. Obviously, as a higher percentage of patients become up to date with the PPSV, a smaller population will remain available to study additional interventions. Once a strategy has achieved maximum effectiveness within the desired population (i.e., saturation effect), other strategies must be used to meet the targeted goal. These approaches should be based on sound scientific principles and clinical research.
Most important, advanced practice nurses has the responsibility to integrate findings from research studies into clinical practice. Using evidence-based practice, providers can truly implement effective strategies to overcome barriers to pneumococcal vaccination in older adults.
Overcoming barriers is essential to enhancing pneumococcal immunization rates within office settings. This integrative review adds to the evidence base that supports the need for sustained organizational change to integrate pneumococcal vaccination into routine clinical care. Although individual provider- and patient-centered approaches demonstrated modest effectiveness within the literature reviewed, the most significant increases in immunization rates occurred when the health care system incorporated changes in staffing and adopted multicomponent interventions.
Because minority groups were underrepresented within the studies included in this review, additional research is needed to determine effective strategies to decrease racial disparities. However, the research reviewed strongly supported the nurse’s role in enhancing vaccination rates, and advanced practice nurses are in a prime leadership position to implement multicomponent organizational change that can enhance immunization rates for older adults, including minority populations.
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- Centers for Medicare & Medicaid Services. (2009). Steps to promoting wellness: Adult immunizations. 2009–2010 immunizers’ question and answer guide to Medicare coverage of influenza and pneumococcal vaccinations. Retrieved from http://www.cms.gov/AdultImmunizations/Downloads/0910QAGuide.pdf
- Chi, R.C., Reiber, G.E. & Neuzil, K.M. (2006). Influenza and pneumococcal vaccination in older veterans: Results from the Behavioral Risk Factor Surveillance System. Journal of the American Geriatrics Society, 54, 217–223. doi:10.1111/j.1532-5415.2005.00577.x [CrossRef]
- Ehresmann, K.R., Ramesh, A., Como-Sabetti, K., Peterson, D.C., Whitney, C.G. & Moore, K.A. (2001). Factors associated with self-reported pneumococcal immunization among adults 65 years of age or older in the Minneapolis-St. Paul metropolitan area. Preventive Medicine, 32, 409–415. doi:10.1006/pmed.2001.0839 [CrossRef]
- Federal Interagency Forum on Aging-Related Statistics. (2008). Older Americans 2008: Key indicators of well-being. Retrieved from http://www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Population.aspx
- Fields, S. & Nicastri, C. (2004). Health promotion/disease prevention in older adults—An evidence-based update. Part II: Counseling, chemoprophylaxis, and immunizations. Clinical Geriatrics, 12(11), 17–25. Retrieved from http://www.clinicalgeriatrics.com/article/3512
- Fishbein, D.B., Willis, B.C., Cassidy, W.M., Marioneaux, D. & Winston, C.A. (2006). A comprehensive patient assessment and physician reminder tool for adult immunization: Effect on vaccine administration. Vaccine, 24, 3971–3983. doi:10.1016/j.vaccine.2006.02.006 [CrossRef]
- Flanders, S. (2001). Chapter 36: Pneumococcal vaccination prior to hospital discharge. In U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality, Making health care safer: A critical analysis of patient safety practices. Retrieved from http://archive.ahrq.gov/clinic/ptsafety/chap36.htm
- Immunization Action Coalition. (2010). Pneumococcus: Questions and answers. Retrieved from www.immunize.org/catg.d/p4213.pdf
- Jacobson Vann, J.C. & Szilagyi, P. (2005). Patient reminder and recall systems to improve immunization rates (Article No. CD003941). Cochrane Database of Systematic Reviews, Issue 3. doi:10.1002/14651858.CD003941.pub2 [CrossRef]
- Johnson, E.A., Harwell, T.S., Donahue, P.M., Weisner, M.A., McInerney, M.J., Holzman, G.S. & Helgerson, S.D. (2003). Promoting pneumococcal immunizations among rural Medicare beneficiaries using multiple strategies. The Journal of Rural Health, 19, 506–510. doi:10.1111/j.1748-0361.2003.tb00589.x [CrossRef]
- Kruspe, R., Lillis, R., Daberkow, D.W. 2nd. , Blais, C.M., Wilbright, W., Gupta, S. & Lopez, F.A.,… (2003). Education does pay off: Pneumococcal vaccine screening and administration in hospitalized adult patients with pneumonia. Journal of the Louisiana State Medical Society, 155, 325–331.
- Latessa, R.A., Cummings, D.M., Lilley, S.H. & Morrissey, S.L. (2000). Changing practices in the use of pneumococcal vaccine. Family Medicine, 32, 196–200.
- Mieczkowski, T.A. & Wilson, S.A. (2002). Adult pneumococcal vaccination: A review of physician and patient barriers. Vaccine, 20, 1383–1392. doi:10.1016/S0264-410X(01)00463–7 [CrossRef]
- Nowalk, M.P., Bardella, I.J., Zimmerman, R.K. & Shen, S. (2004). The physician’s office: Can it influence adult immunization rates?American Journal of Managed Care, 10, 13–19.
- Pham, H.H., Schrag, D., Hargraves, J.L. & Bach, P.B. (2005). Delivery of preventive services to older adults by primary care physicians. Journal of the American Medical Association, 294, 473–481. doi:10.1001/jama.294.4.473 [CrossRef]
- Quinley, J.C. & Shih, A. (2004). Improving physician coverage of pneumococcal vaccine: A randomized trial of a telephone intervention. Journal of Community Health, 29, 103–115. doi:10.1023/B:JOHE.0000016715.91811.4b [CrossRef]
- Rubins, J.B. & Janoff, E.N. (2001). Pneumococcal disease in the elderly: What is preventing vaccine efficacy?Drugs and Aging, 18, 305–311. doi:10.2165/00002512-200118050-00001 [CrossRef]
- Russo, C.A. & Elixhauser, A. (2006). Hospitalizations in the elderly population, 2003. Retrieved from the Agency for Healthcare Research and Quality website: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb6.pdf
- Santibanez, T.A., Nowalk, M.P., Zimmerman, R.K., Jewell, I.K., Bardella, I.J., Wilson, S.A. & Terry, M.A. (2002). Knowledge and beliefs about influenza, pneumococcal disease, and immunizations among older people. Journal of the American Geriatrics Society, 50, 1711–1716. doi:10.1046/j.1532-5415.2002.50466.x [CrossRef]
- Santibanez, T.A., Zimmerman, R.K., Nowalk, M.P., Jewell, I.K. & Bardella, I.J. (2004). Physician attitudes and beliefs associated with patient pneumococcal polysaccharide vaccination status. Annals of Family Medicine, 2, 41–48. Retrieved from http://www.annfammed.org/cgi/reprint/2/1/41 doi:10.1370/afm.53 [CrossRef]
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- Szilagyi, P.G., Bordley, C., Vann, J.C., Chelminski, A., Kraus, R.M., Margolis, P.A. & Rodewald, L.E. (2000). Effect of patient reminder/recall interventions on immunization rates: A review. Journal of the American Medical Association, 284, 1820–1827. doi:10.1001/jama.284.14.1820 [CrossRef]
- Terrell-Perica, S., Effler, P.V., Houck, P.M., Lee, L. & Crosthwaite, G.H. (2001). The effect of a combined influenza/pneumococcal immunization reminder letter. American Journal of Preventive Medicine, 21, 256–260. doi:10.1016/S0749-3797(01)00372-5 [CrossRef]
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- Winston, C.A., Mims, A.D. & Leatherwood, K.A. (2007). Increasing pneumococcal vaccination in managed care through telephone outreach. American Journal of Managed Care, 13, 581–588.
- Winston, C.A., Wortley, P.M. & Lees, K.A. (2006). Factors associated with vaccination among Medicare beneficiaries in five U.S. communities: Results from the racial and ethnic adult disparities in immunization initiative survey, 2003. Journal of the American Geriatrics Society, 54, 303–310. doi:10.1111/j.1532-5415.2005.00585 [CrossRef]
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Summary of the Integrative Literature Review
||Population, Setting, and Location
|Chi, Reiber, and Neuzil (2006)
||To compare influenza and pneumococcal vaccination rates of older veterans to nonveterans and to compare veterans who receive care at VA medical centers with those who do not
||13,999 veterans and 40,331 non-veterans and 3,265 VA users and 10,677 non-VA users age 65 and older residing in United States and U.S. territories who participated in the 2003 BRFSS
||Descriptive, population-based telephone study examining organizational change through multicomponent interventions
||Comparison of immunization rates
||Pneumococcal vaccination rates were higher for veterans than nonveterans (68% versus 63%) and for VA users than non-VA users (81% versus 64%)
|Fishbein, Willis, Cassidy, Marioneaux, and Winston (2006)
||To evaluate effectiveness of a patient A/R tool in increasing immunization rates in adults
||Convenience sample of 200 adults (100 control and 100 intervention) from three varied family practice settings in Georgia (GA), New Mexico (NM), and Louisiana (LA)
||Quasi-experimental study in which A/R tool served as patient educator and provider reminder
||Percentage of intervention patients immunized compared with control
||PPSV was administered significantly more often to intervention than control patients in NM (35% versus 3%); no significant difference in PPSV vaccination rates in the GA or LA settings
|Johnson et al. (2003)
||To evaluate effectiveness of a community-wide education campaign and mailed reminders
||Medicare beneficiaries in media markets in rural Montana
||Before-and-after study in which one media market received community education plus mailed reminders; the second media market received only the mailed reminders
||Immunization rates by insurance claims
||Although there was a 10% increase in awareness of PPSV, the education and reminder resulted in only a 3.7% increase in PPSV rates
|Latessa, Cummings, Lilley, and Morrissey (2000)
||To determine whether a CQI process or patient education intervention results in increased PPSV rates
||Adults 65 and older and diabetic patients ages 2 to 64 (N = 778 patients cared for in family practice residency program clinic)
||Non-RCT in which CQI process included reminder sticker on chart and patient education sign
||Combination of provider reminder and patient education increased PPSV rates by 20%; education alone increased PPSV 11%; control group rates increased 7%
|Nowalk, Bardella, Zimmerman, and Shen (2004)
||To determine office and patient factors that affect adult influenza and pneumococcal vaccination rates
||22 practices within 4 strata in Pennsylvania; patients were 66 and older (95% White; 54% men)
||Descriptive study using questionnaires for office managers and patient interviews; included individual and multicomponent strategies
||Immunization rates and immunization status
||Use of three or more strategies increased PPSV rates (OR = 1.97, 95% CI: 1.33, 2.94); longer time for acute care visits (16 to 20 minutes versus 10 to 15 minutes) increased PPSV rates (OR = 1.94, 95% CI: 1.18, 3.19; p = 0.011)
|Pham, Schrag, Hargraves, and Bach (2005)
||To determine physician and practice factors associated with delivery of preventive services to older adults
||3,660 physicians providing care to 24,581 Medicare beneficiaries (88.2% White, 7.6% Black; 63.5% women) 65 and older
||Descriptive study; analysis of 2000–2001 Community Tracking Study Physician Survey using individual and multicomponent factors/strategies
||Proportion of beneficiaries receiving PPSV and other recommended preventive services
||Availability of IT to access clinical guidelines or generate reminders was associated with increased frequency of administering PPSV (8.6% versus 7.2%)
|Quinley and Shih (2004)
||To examine effectiveness of adding a telephone follow up to a mailed provider performance feedback
||High-volume primary care physician offices in New York (n = 732) or practices serving African American patients (n = 329)
||RCT with all practices receiving mailed provider feedback on PPSV coverage rates; intervention group received telephone follow up
||Immunization rates by insurance claims
||Telephone reminders increased PPSV rates (27% versus 17%); PPSV rates increased in high-volume practices from 22% to 34% and at least 5% in practices serving African American patients
|Santibanez, Zimmerman, Nowalk, Jewell, and Bardella (2004)
||To investigate predisposing, enabling, environmental, and reinforcing factors to patients receiving PPSV
||60 primary care physicians from inner-city, rural, suburban, and VA practices caring for adults 65 and older (83% White, 33% women)
||Descriptive study using physician and patient questionnaires and personal interviews of patients conducted by trained interviewers; individual and multicomponent strategies examined
||PPSV immunization status
||Factors significantly associated with PPSV status included having a clinic or specific program to enhance immunizations (76% versus 63%) and using provider reminders (77% versus 63%)
|Terrell-Perica, Effler, Houck, Lee, and Crosthwaite (2001)
||To evaluate the effectiveness of a combined influenza and pneumococcal immunization reminder letter
||6,528 newly enrolled Medicare beneficiaries in Hawaii
||RCT in which intervention arms included influenza-only reminder (n = 2,213) or combined influenza and pneumococcal letter (n = 2,171)
||Immunization rates by insurance claims
||The combined letter increased PPSV rates 3.5% over control (no letter) and 4% over influenza-only letter
|Winston, Mims, and Leatherwood (2007)
||To determine effectiveness of telephone reminder for PPSV immunization and to evaluate the intervention effect among races
||6,106 unvaccinated patients 18 and older with chronic medical conditions and those 65 and older without chronic medical conditions within five managed care network general medicine clinics in Atlanta
||RCT including 2,395 healthy older adults (n = 1,197 control; n = 1,198 intervention); race and ethnicity were not in database (clinic location served as proxy for race and ethnicity); intervention included an RN call to patients noting PPSV recommendation and covered benefit
||Percentage of patients receiving PPSV within 6-month period following intervention
||Of the older adults, 17% of intervention patients were vaccinated, compared with 8% of controls; in subanalyses of older adults reached by telephone, unvaccinated Black adults were less likely to be vaccinated during the study than unvaccinated White adults (24% versus 34%)
|Zimmerman et al. (2009)
||To assess practice interventions and characteristics associated with increased influenza and PPSV rates
||2,021 patients 65 and older receiving care from 30 physicians in 17 practices; 81.2% of patients were White, mean age = 76, neighborhood average income = $19,439
||Descriptive study with intentional sample of diverse practice types including observation of visits; survey to identify office systems; and HLM analyses of relationships among immunization rates, interventions and practice characteristics, and patient variables
||PPSV and influenza immunization rates in relation to practice and patient characteristics
||Weighted PPSV vaccination rate was 65.5% for White adults versus 36.6% for minorities; use of reminders was associated with a 66.7% PPSV rate; higher vaccination rates were associated with increased time spent with patients for well visits (HLM p = 0.009)